Breast surgery: augmentation, reduction and mastopexy

The difference patients actually perceive lies in softness and how the shape changes between standing and lying. Motiva Ergonomic gel tends to settle into the lower pole when upright and redistribute when supine, closely mimicking natural breast behaviour. Mentor Gel Xtra is firmer and holds its shape more consistently, which suits patients with thin tissue who need structural support.

In patients with thin glandular tissue, an overly firm gel readily shows the implant edge at the upper pole. In those with dense tissue, a softer gel may not create the fullness sought. This is why implant selection must follow actual measurement rather than brand preference.

What influences the outcome more than implant choice is accurate breast base measurement, correct volume and profile selection, the plane of placement and pocket dissection technique. A good implant placed poorly still produces a poor result.

The belief that implants "must be replaced after 10 years" is a common misconception. No medical guideline requires scheduled replacement in an asymptomatic patient with normal imaging.

What is recommended is regular surveillance. For silicone gel implants, international guidance advises scheduled ultrasound or MRI to detect silent rupture, since cohesive gel rupture often produces no change in breast shape and no symptoms.

The most frequent reason for revision in practice is not implant failure but change in the surrounding breast tissue: age-related ptosis, or volume change after pregnancy or weight loss. Management then usually involves mastopexy with implant exchange rather than exchange alone.

If you plan future pregnancies, state this at the consultation. It directly influences incision choice and implant plane, which can be adjusted to preserve glandular function as far as possible.

This must be distinguished from breast reduction. Reduction involves excising glandular tissue and repositioning the nipple-areola complex, so its impact on lactation is considerably greater than implant augmentation.

Pregnancy and lactation alter breast volume and ptosis even with implants in place. This is why RASA often advises timing augmentation around family plans, not because of medical risk but because of the durability of the aesthetic result.

Severity is graded on the Baker scale from I to IV. Grades I and II usually require no intervention. Grades III and IV cause visible distortion or pain and require revision surgery with capsulectomy and implant exchange.

Risk-reduction measures used at RASA include strict aseptic technique, minimising implant exposure to air and skin, using an insertion sleeve, irrigating the pocket with antimicrobial solution, and meticulous haemostasis to avoid haematoma. Postoperative haematoma is one of the clearest risk factors.

No measure eliminates this risk entirely. If a previously soft breast becomes progressively firm, changes shape or rides higher than before, contact your surgeon for assessment rather than waiting.

The periareolar scar is less conspicuous because it sits at a colour boundary, but the approach traverses glandular tissue, raising the risk of ductal disruption and of infection through contact with the ductal system. It suits patients with an adequately sized areola.

The transaxillary approach leaves no scar on the breast, but surgical exposure is more limited, pocket refinement and haemostasis are harder, and revision usually requires an additional incision.

No single approach is best in all cases. The choice depends on breast anatomy, implant type, family plans and how you weigh scar position against surgical precision.

In current practice the most common choice is dual-plane placement, combining both advantages: the upper pole is covered by muscle to prevent edge visibility, while the lower pole sits directly behind the gland so the implant drapes naturally.

The upper pole pinch test is the practical determinant: if pinchable tissue thickness is under roughly 2cm, subglandular placement risks visible implant edges and should be avoided.

For patients who train the upper body heavily, animation deformity on pectoral contraction is a consideration when choosing a submuscular plane.

The cc figure causes more confusion than anything else in augmentation consultations. The same 300cc looks entirely different on two patients with differing base width and tissue thickness. Implant width and profile are the two parameters that determine shape.

An implant too large for the supporting tissue produces late consequences: progressive skin thinning, edge visibility and rippling, early ptosis, and in some cases inferior implant migration below the fold. This is a common reason for revision after a few years.

RASA combines clinical measurement with in-bra sizer trials so you can visualise the result before deciding. The goal is the largest volume your tissue can support durably, not the largest volume that will physically fit.

The gradual movement from an initially high position into the designed pocket is part of implant settling. The two sides may not progress at exactly the same rate because swelling, muscle tone and baseline anatomy are rarely identical.

Do not massage forcefully or try to push an implant down unless specifically instructed. Postoperative handling differs according to surgical technique and pocket condition; a manoeuvre suitable for one patient may be inappropriate for another.

Increasing redness, heat or pain, rapid one-sided swelling, wound discharge or a sudden change in implant position warrants early contact with the surgical team rather than waiting for the 3 to 6 month mark.

Sensation to the nipple-areola complex is supplied mainly by intercostal nerve branches entering from the lateral breast. Excessively wide pocket dissection or an implant that places substantial tension on the breast base increases the risk of sensory disturbance.

A periareolar incision passes closer to glandular tissue and the sensory network than an inframammary incision, so this trade-off deserves particular attention in patients who prioritise sensation and future breastfeeding.

Intermittent tingling and patchy numbness can occur as nerves recover. Loss of sensation accompanied by nipple colour change, increasing pain or a wound abnormality should be assessed promptly.

Reference photographs are useful for describing a preference such as upper-pole fullness, a gentle slope or more visible cleavage. They are not a template that can be copied because chest width, tissue thickness and nipple position differ between individuals.

The surgeon selects implant diameter and profile to improve medial fullness while remaining within the breast footprint. An overly wide implant can cross toward the midline, extend into the axilla, thin the tissue and increase long-term edge visibility.

In patients with thin tissue or widely separated breast bases, adjunctive fat grafting may soften the medial transition. Its effect is limited and it cannot replace the underlying anatomy.

These are reference ranges rather than a fixed schedule for everyone. Submuscular placement, augmentation combined with mastopexy and revision surgery generally require a more cautious progression than straightforward subglandular augmentation.

During early recovery, a postoperative bra helps control swelling and limits unwanted implant movement. Do not switch to an underwired bra, increase compression or stop wearing support early without confirmation from the surgical team.

When returning to exercise, increase load gradually and stop if sharp pain, one-sided tightness or increased swelling follows a session. Review findings matter more than trying to meet a generic timeline found online.

If you still plan to have children, discuss this openly beforehand. In many cases the sensible option is deferring reduction until after your last delivery, since pregnancy also alters volume and ptosis and can undermine the result already achieved.

The full picture matters. Breast hypertrophy is not only an aesthetic concern: it causes neck and shoulder pain, back pain, bra strap grooving, inframammary intertrigo and restricted activity. For symptomatic patients the benefit usually outweighs the trade-offs, and this is a genuine medical indication.

Reduction leaves more scarring than augmentation, typically an inverted-T or vertical pattern. This trade-off must be accepted before deciding.

This is the most common indication error in breast surgery. Placing a large implant in a significantly ptotic breast adds load to already weakened tissue, accelerating ptosis and producing the picture of a high-riding implant with glandular tissue sliding beneath it.

A rough self-assessment: stand upright before a mirror and note nipple position relative to the inframammary fold. This is the basis of the Regnault ptosis grading surgeons use.

Where both volume loss and ptosis are present, the answer is mastopexy combined with augmentation in a single stage. This is more complex with more scarring, but it is the correct indication. Accepting additional scarring for a durable result is usually the sounder choice.

The best candidates want a moderate volume increase, have adequate abdominal or thigh fat, and value natural feel over size. Slim patients often lack sufficient donor tissue.

Breast fat grafting is also highly effective as an adjunct: masking implant edges in thin-tissue patients, correcting asymmetry, and softening the upper pole transition. This may be its most valuable application.

A screening note: breast fat grafting can produce calcifications or oil cysts, and radiologists need to know this in advance to distinguish them from malignant lesions. Always disclose a history of fat grafting when attending for mammography.

BIA-ALCL is a disease of the periprosthetic capsule, not of breast glandular tissue. Incidence is very low and most cases detected early are cured by en bloc capsulectomy and implant removal. The warning sign is unexplained breast swelling after years of stability, or a new mass.

Following the BIA-ALCL data, the field has shifted substantially towards smooth or nanotextured shells. Implant selection now takes this into account.

One point deserves emphasis: having implants does not exempt you from routine breast cancer screening. Self-examination, ultrasound and age-appropriate mammography schedules remain the same as for anyone else.

Implants obscure part of the glandular tissue on standard mammographic views, which is why the additional projections are necessary rather than optional. Submuscular placement obscures less than subglandular.

Screening retains its value when performed with the correct technique. What must be avoided is skipping screening in the belief that implants preclude imaging, a misconception with serious consequences.

Keep the implant information card provided by your surgical facility, recording manufacturer, shell type, volume and lot number. This is useful both for radiologists and for any future intervention.

Revision is generally more complex than primary surgery because it involves scarred tissue, an established pocket and altered anatomy. Preoperative assessment therefore needs to be more thorough, sometimes including MRI to evaluate the implant and capsule.

For thin-tissue patients with visible edges, the solution is usually not implant exchange alone but adding coverage: peripheral fat grafting, or converting from a subglandular to a submuscular plane.

RASA accepts assessment of cases operated elsewhere. If you still have your implant details and the original operative note, bring them; this makes planning considerably more accurate.